What is an Electronic Health Record?

what-is-an-electronic-health-recordTechnology has impacted healthcare in many ways, but one of the biggest advances has been the introduction of the Electronic Health Record.

There are images throughout literature, humorous anecdotes and illustrations of the doctor scribbling illegible notes into a metal-sheathed file while nurses look on in dismay. That dismay was probably caused by the fact that the nurse, or someone else in the office, would probably be called upon to transcribe those scribblings into legible records.

The examples become less humorous, however, when errors are made in transcription or when some facts are not mentioned. The concern over the results of such errors led the U.S. government to draft the 2009 HITECH Act, which set medical facilities down a path with no return.

What is the EHR?

Simply put, according to Health IT.gov, it is the information usually contained in a paper record but in digital form. Of course, that is a great simplification because technology has enabled hospitals and physicians to do so much more with the innovation. Advances in computerized x-ray machines, vital statistic monitors and other equipment allow data to be entered automatically into the EHR without transcription. Not only does the patient record note that there is a heart arrhythmia, for instance, but the ECG tape itself appears in the patient record.

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The EHR contains patient history, diagnoses, treatments, inoculations, allergies and sensitivities, medications and prescriptions, x-ray and lab results and other data. Another digital document, the EMR, is stored in the hospital or clinic for limited access but the electronic health record is sent to a central location where doctors and other practitioners can access the information instantly.

Advantages of the EHR

Aside from the difficulty in understanding handwritten information noted above, there are other reasons to use EHRs. First, the information is available to many healthcare providers. That means patients referred to specialists or other practitioners don’t have to fill out the same forms at each office. The process is made easier for patients, but also ensures that the same information is given to each provider, as patients might forget to list information, such as allergies, at one office and include it at another.

Second, doctors have access to information before they see the patient. Another benefit is that patients have portals into their records that enable them to be proactive in their health care. Once the software is enabled the chances of duplicated billings and billing for the wrong procedures are reduced.

Disadvantages of EHRs

As positive as the impact of these digital records is, there are some concerns about them. Healthcare IT News notes privacy as a big issue. Paper records are stored in a physical file at one location so access is restricted, but EHRs are available to multiple viewers. That raises the possibility of litigation for invasion of privacy if someone without authorization views the files. Another issue is the lack of standardized terminology and methodology. The EHR systems don’t always communicate with one another.

Besides these concerns, transitioning from paper to the EHR can be costly. Purchasing the system is only the beginning; afterward, personnel must be trained and equipment obtained that interfaces with the digital records.

There are “fixes” to the disadvantages. If that were not so, the government would not have endorsed the HITECH Act that offers financial incentives to providers that make the transition. Those incentives began in 2011 and ended in 2015, when penalties are imposed upon health care facilities and providers that do not use EHR systems.

The technology is constantly evolving and the hope is that it will eventually be standard in the healthcare industry. The Electronic Health Record is here to stay.